In this article, the authors aim to thoroughly describe the critical surgical anatomy of the facial layers, the retaining ligamentous attachments of the face, and the complex three-dimensional course of the pertinent nerves. This is supplemented with clarifying anatomic dissections and artwork figures whenever possible to enable easy, sound, and safe navigation during surgery. The historic milestones that led the evolution of cervicofacial rejuvenation to the art we know today are summarized at the beginning, and the pearls of the relevant facial analysis that permit accurate clinical judgment and hence individualized treatment strategies are highlighted at the end. Read More

Authors:

Department of Anatomy, Phramongkutklao College of Medicine, Royal Thai Army, Bangkok, Thailand.

Background: This study aimed to reveal the anatomical variation in the great auricular nerve (GAN) and the correlation between the size of the GAN and the facial nerve trunk (FNT), so as to aid surgeons to perform safe facelift surgery and parotidectomy.

Methods: Sixteen human cadavers were studied on 16 left and 15 right facial sides. The GAN's branching patterns, location, and the mean width of the GAN and FNT were measured. Read More

Authors:

Division of Facial Plastic and Reconstructive Surgery, Department of Head and Neck Surgery, University of California, Los Angeles, Los Angeles, California.

In surgery of the aging face, operative adjustments of the superficial musculoaponeurotic system (SMAS) enhance facial contours. The senior author has observed that the standard deep plane face lift entry points on the SMAS do not provide as much tissue movement in a vertical direction as high-SMAS deep plane face lift entry points. In this study, tissue movement was measured comparing the conventional SMAS entry point with a high-SMAS entry point for deep plane face lifts. Read More

Authors:

Department of Pathology, Anatomy, and Laboratory Medicine (PALM), Robert C. Byrd Health Sciences Center, West Virginia University School of Medicine, Morgantown, WV, USA.

Purpose: Submental anatomical variation is of clinical importance with regard to head and neck surgeries. One such anatomical variation is that of additional musculature joining the intermediate tendon of the digastric muscle to the midline of the mylohyoid musculature-a variation which this report refers to, accordingly, as an arrowhead variation. Though the arrowhead variation has been described in several case reports, it has not been subject to cross-sectional study. Read More

Authors:

Center for Facial Plastic and Laser Surgery, Charlotte, North Carolina.

In this article, the interested reader will learn when and how to apply different techniques on their patients, with the goal of safe, effective, natural looking, and long-lasting midface rejuvenation. Read More

Authors:

Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.

Rejuvenation of the lower face and neck strives to reverse signs of aging while optimizing the patient's natural anatomy. Common features of an aesthetically pleasing lower face include a well-defined and appropriately balanced mandible and an acute cervicomental angle. Correction of the aging lower face and neck is accomplished through multiple surgical interventions, performed either alone or in combination. Read More

Neck rejuvenation attempts to correct the unattractive features that result from the process of facial aging. The aesthetic goals of surgery include creating a well-defined jaw contour, optimal cervicomental angle, smooth-appearing skin, and a healthy redistribution of soft tissue volume. Unique patient characteristics create inherent challenges that may limit the degree to which improvement can be made. Read More

Authors:

For a subset of patients poor neck contour exists as a largely isolated problem and can be treated with a short scar neck lift procedure whereby no skin is removed. The procedure is performed through a submental incision without any removal of skin and relies on modification of deep-layer structures to improve neck contour. "Excess" skin is allowed to redistribute itself over the increased neck surface area created when deep-layer maneuvers are performed, neck contour is improved, and the cervicomental angle deepened. Read More

Authors:

Microneedling was first described in 1995 by Orentreich and Orentreich for the treatment of atrophic scars and wrinkles.1 The local injury induced by dermal penetration of microneedling causes release of growth factors such as transforming growth factor (TGF)-α, TGF-β, and platelet-derived growth factor (PDGF). This stimulates collagen and elastin fiber production as well as capillary formation, ultimately leading to tissue remodeling. Read More

Technique: Thorough pre-operative patient screening and counseling are completed in an outpatient cosmetic surgery center. A super-high SMAS flap is developed by undermining and incising along a line extending from the tragus to lateral canthus and dissecting the SMAS sufficiently to induce movement of the lateral nose and the oral commissure with traction on the SMAS. Read More

Authors:

Groningen, Zwolle, and Heerenveen, The Netherlands; and San Francisco, Calif. From the Department of Plastic Surgery, University and University Medical Centre of Groningen; the Department of Clinical Psychology, University of Groningen; Bergman Clinics; and Marten Clinic & Plastic Surgery, San Francisco, Calif.

Background: The aim of this study was to test the validity of the "orbital oval balance principle," a system of analysis and guideline that is used among aestheticians, artists, and makeup artists to create and design aesthetically pleasing eyebrows for optimal upper facial appearance. According to this principle, a face is optimally attractive when the eye is centered in an "oval" defined by the lid-cheek junction and the eyebrow.

Methods: One hundred participants were asked to rank digital morphed images of four female models with four different periorbital proportions: higher or lower lid-cheek junction versus higher or lower eyebrow position. Read More

Authors:

Department of Oral and Maxillofacial-Head and Neck Oncology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine.

Objectives: The purpose of this article was to propose a V-shaped minimal facelift incision (FLI) and analyze its efficacy for improving the esthetic outcomes of parotid gland tumors.

Methods: A prospective, nonrandomized study was performed. Forty-six patients with category I benign parotid tumors as to Quer classification (3 cm or less and located superficially and/or peripherally in the gland) were enrolled. Read More

Authors:

A complete approach to facial rejuvenation includes restoration of the skin's surface, relaxation of muscles that contribute to hyperkinetic movement, revolumization, and repositioning/recontouring of descended tissues and fat pads. After receiving 510(k) clearance from the US Food and Drug Administration (FDA) in 2015, the Silhouette InstaLift™ absorbable suspension suture became the only available non-surgical technique for repositioning of facial tissue. In January 2017, a consensus paper presented a review of the literature on the efficacy and safety of absorbable suspension sutures and provided information on treatment procedures. Read More

Authors:

The Third Department, Plastic Surgery Hospital, Peking Union Medical College and the Chinese Academy of Medical Sciences, Beijing, China.

Forehead aging is characterized by wrinkles, loss of skin elasticity, brow ptosis, and soft-tissue atrophy. For patients with prominent rhytids and marked brow ptosis, forehead lift is still the most effective treatment with a persisting result. In order to eliminate the glabellar wrinkles, forehead lift usually requires the removal of the corrugator supercilii muscle and procerus, which can lead to glabellar flattening or depression. Read More

Greater life expectancy with advancements in technology and medicine has led to an increasing interest in facial rejuvenation. Facial aging is an inevitable process that largely results from soft tissue descent and volumetric deflation. However, a comprehensive knowledge of the aging process and precise assessment of the exact pathologies yielding the patient's senescent appearance is essential to produce the best cosmetic outcome. Read More

Authors:

The temples are an often overlooked, but important element of facial rejuvenation. The anatomy of the temple should be understood prior to any intervention in this location. Multimodal treatment to re-establish youthful convexity, proper hairline position, and correct actinic damage is recommended for optimal results. Read More

Authors:

Lindsay House Surgery Center for Plastic Surgery, Rochester, New York.

The endoscopic brow lift has become an established procedure that can safely and reliably rejuvenate the upper third of the face. The authors discuss relevant anatomy and considerations for patient selection to optimize surgical outcomes. A detailed review of surgical technique is presented, and the potential complications and means to reduce them are discussed. Read More

Authors:

A hallmark of the modern era of facial plastic surgery is the increasing demand for upper facial rejuvenation by both genders and the growing variety of such options, including both surgical and non-surgical modalities. Thus, now more than ever, differentiating these aesthetic ideals between the two genders and understanding their nuances has become a necessity for the facial cosmetics community. In this article, a detailed comparison of the the pertinent anatomical and topographical differences is presented, followed by a review of the historical evolution of these aesthetic trends. Read More

Aesthetic ideals regarding proportion and balance of the face have existed for centuries. The upper third of the face, including the brow, forehead, and temple, provides an important contribution to the overall facial aesthetic. This is especially true given how the brow frames the eyes, and the eyes serve as the key focal point in our interactions with others. Read More

Authors:

Department of Plastic Surgery, Inha University School of Medicine, Incheon, South Korea.

Purpose: The aims of this study were to characterize the histology of the sideburn and cheek area and to measure the force required to pull the superficial fascia (SF) of Asians in facelift procedures.

Methods: The hemiface of a formalin-fixed Korean male adult cadaver (77 years old) was used to study the histology of the sideburn and cheek area. In 42 patients during facelift procedures, the force needed to pull the overlying skin at the midpoint between the sideburn and nasolabial fold 2 mm was measured using a tensiometer. Read More

Vascular abnormalities are localized structural irregularities, which are performed during vasculogenesis, angiogenesis, and lymphangiogenesis. The involvement of soft tissue in such vascular malformations is frequent; however, the compromising of the buccal fat pads (Bichat bags) is uncommon, even in specialized centers, such as the plastic clinic of our institution, in which very few patients have been reported in the literature. The purpose of this article is to present a series of 2 patients in which vascular malformations involving the buccal fat pads, which were extracted by intraoral approach. Read More

Background: Inadequate release of retaining ligaments during facelift surgery may lead to an unnatural appearance. However, most facelift surgeons are hesitant in transecting these ligaments to avoid possible injury to facial subbranches.

Objectives: In the authors' surgical practice for modified composite flap rhytidectomy, the authors employed the finger-assisted malar elevation (FAME) technique in order to enable safe release of the zygomatic cutaneous ligaments through the prezygomatic space under direct vision. Read More

Authors:

The aim of this study is to search for the origin of the term "ligament' in the face, present its status, and suggest a principle to rectify the use of unclear terminology.The structure that connects the zygoma to the skin was first presented by McGregor (1959). Kaye (1981), in describing his "extended facelift," wrote that the adherent area of the cheek over the malar eminence (McGregor's patch) usually requires sharp dissection. Read More

Authors:

Objective: To evaluate the effectiveness of a topical silicone gel on scars in patients who had undergone bilateral direct brow lift surgery.

Design: A randomized double-blind clinical trial with a placebo applied to one scar and topical silicone gel (Dermatix Ultra; Valeant Pharmaceuticals, Laval, Que.) used on the other scar for 2 months. Read More

Authors:

Patients with thick skin typically present with a redundant, baggy, lax skin envelope together with prominent nasolabial folds, jowls, and a heavy neck. Durable and natural-appearing rejuvenation is not possible unless the deformities are addressed adequately and harmoniously in these patients. Traditional superficial musculoaponeurotic system techniques do not include surgical release of the zygomatic cutaneous ligaments and repositioning of descendent malar fat pad, and may lead to an unbalanced, unnatural appearance and the lateral sweep phenomenon. Read More

Authors:

Background: In the malar region, the SMAS flap can be thin and tear easily, making it difficult to securely fix it. And the surgical anatomy of the region may be unclear and confusing. The authors performed an anatomical study on the location of the lateral margin of the orbicularis oculi muscle (OOM) and the origin of the zygomaticus major muscle (ZMM) when using a high-SMAS facelift with finger-assisted spaces dissection technique, which included elevation of the SMAS flap with OOM. Read More

Authors:

Department of Anatomy, Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea.

This study aimed to present the anatomic characteristics of osteoperiosteal ligamentous attachments of the forehead and provide a better understanding of lateral eyebrow descent for safe and effective foreheadplasty. Anatomic dissections of the face were performed in 10 fresh Korean adult cadavers (20 hemifaces) using 2.5× magnification surgical loupes. Read More

Background: In previous papers, we demonstrated that the treatment of human photoaged skin with stromal-vascular fraction-enriched fat or expanded adipose-derived stem cells showed a decrease of elastosis and the appearance of new oxytalan elastic fibers in dermis and an increase in the vascular network. The utilization of fat plus platelet-rich plasma (PRP) led to an increase in the vascular permeability and reactivity of the nervous component.

Objectives: The purpose of this study was to analyze the histologic and ultrastructural changes of human skin after the injection of only PRP in the retroauricular area that was not exposed to sun and did not present the photoaging process, in comparison with our previous results. Read More

Authors:

Groningen, The Hague, Heerenveen, and Zwolle, The Netherlands From the Departments of Plastic Surgery, Pathology and Medical Biology, and Epidemiology, University of Groningen, University Medical Centre Groningen; and Bergman Clinics.

Background: Lipofilling is a treatment modality to restore tissue volume, but it may also rejuvenate the aging skin. Platelet-rich plasma has been reported to augment the efficacy of lipofilling, both on graft take and rejuvenation, by altering the adipose-derived stem cells. The authors hypothesized that addition of platelet-rich plasma would increase the rejuvenating effect and shorten recovery time. Read More

Authors:

The first step to determine a medical or surgical intervention is the clinical exam. The clinical exam is the paramount step to provide a treatment plan that can be modified and individualized accounting the patient preferences. During the consultation for facial rejuvenation, attention should be paid to understand the patient's motivation and expectations. Read More

Authors:

São Paulo, Brazil; Aalst, Belgium; Rio de Janeiro, Brazil; and Dallas, Texas From the Clinica Dr. Maurício de Maio; the Aalst Dermatology Clinic, private practice; and the University of Texas Southwestern Medical Center.

This second article of a three-part series addresses techniques and recommendations for aesthetic treatment of the midface. Injectable fillers are important for rejuvenation of the midface by replacing lost volume and providing structural support; neuromodulators play a smaller role in this facial region. Fillers are used for volumization and contouring of the midface regions, including the upper cheek and lid-cheek junction and the submalar and preauricular areas. Read More

Authors:

In rhinoplasty patients radix position profoundly impacts the appearance of the nasal profile by influencing dorsal length, contour, angulation, and height. The authors wanted to introduce a new perspective to radix, and decided to focus on subcutaneous tissues, especially procerus muscle. Actually resection of procerus and corrugator supercilii is a part of browlift and endoscopic facelift techniques, with which the authors are already familiar. Read More

Authors:

The goal of this article is to provide a systemic approach to forehead rejuvenation. Fillers, botulinic toxin injections, transpalpebral, endoscopic or bicoronal brow lift must be usual techniques for every plastic surgeon in overall facial rejuvenation. Achieving a long lasting and aesthetically pleasing forehead is possible only with surgical techniques when aging is obvious. Read More

The understanding of the face anatomy is mandatory before to be able to appreciate the different surgical techniques of face lifting. Despite numerous controversies and anatomical variations, we can find in the literature several keystone works that allows us to understand that the soft tissues of the face are not only a superposition of layers but also a tridimensionnal structure with a fibrous system that links the different layers. This structures creates a mix loose spaces, fat and retaining ligament that can be describe in a quite systematic manner. Read More

Authors:

The improved understanding of the functional anatomy of the face and of the action of the botulinum toxin A leads us to determine a new injection procedure which consequently decreases the risk of eyebrow and eyelid ptosis and increases the toxin's injection possibilities and efficiencies. With less units of toxin, the technique herein described proposes to be more efficient on more muscles: variable toxin injections concentration adapted to each injected muscle are used. Thanks to a new procedure in the upper face, toxin A injection can be quite close to an endoscopic surgical action. Read More

The eyelid-cheek junction is a key area which generates many comments: from looking tired to looking good or rested, without forgetting charm, beauty, and a youthful appearance. In spite of many interesting medical and surgical procedures, treating this area is sometimes difficult and results are not always up to our expectations. Standardized blepharoplasty, which has often been improperly used, has shown its limits. Read More

Authors:

Philadelphia, Pa.; and Dallas, Texas From the Department of Surgery, Division of Plastic Surgery, Temple University; and the Department of Plastic Surgery, University of Texas Southwestern Medical Center.

Anatomical study has proven vital to the understanding and improvement of rejuvenation techniques of the face and neck. The microscopic septa responsible for individual facial fat compartments are also present in the neck. The authors' anatomical studies of the neck, including supraplatysmal and subplatysmal elements, have influenced their surgical and nonsurgical techniques. Read More

Authors:

Facelift under local anesthesia: the author recounts his experience and methodology developed to operate facelift under local anesthesia in order to reduce operative morbidity and be able to operate persons who do not desire general anesthesia. The technique is based on the knowledge of the sensitive anatomy of the face as well as the practice of sensitive conduction blocks at the level of the face allowing to decrease the doses of local anesthetics. Read More

Authors:

The temporal region has imprecise limits in the young patient. During the aging process, it becomes individualized with the appearance of a temporal fossa, the temporal, orbital and zygomatic bone margins, the ptosis of the lateral part of the brow and the appearance of the wrinkles of the crow's foot. As this area frame the look, it should be taken into consideration during the clinical examination as well as the facial and cervical stages. Read More

Authors:

A histological evaluation of peeling-induced skin changes in subcutaneous undermined preauricular facial skin flaps of nine patients was performed. There were three treatment groups: Trichloroacetic acid (TCA) 25%, TCA 40% and phenol/croton oil; one group served as control. Two independent evaluators determined the epidermal and dermal thickness and the depth of necrosis (micrometre). Read More

Authors:

The Chula Soft Cadaver Surgical Training Center and Department of Anatomy, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.

Periauricular paresthesia may afflict patients for a significant amount of time after facelift surgery. When performing face and neck lift surgery, temple and posterior auricular flap dissection is undertaken directly over the auriculotemporal, great auricular, and lesser occipital nerve territory, leading to potential damage to the nerve. The auriculotemporal nerve remains under the thin outer superficial fascia just below the subfollicular level in the prehelical area. Read More

Authors:

Shanghai, People's Republic of China From the Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine.

Background: Masseter-to-facial nerve transfer is a highly efficient technique for reanimating paralyzed muscle and has been reported to restore facial symmetry at rest. However, no systematic studies have been performed, and the effects of preoperative droop of the oral commissure on postoperative symmetry at rest have rarely been reported.

Methods: The authors retrospectively analyzed 35 patients with masseteric-to-facial nerve anastomosis and assessed the quality and quantity of the dynamic recovery and the oral commissure symmetry at rest. Read More

Authors:

There are multiple factors contributing to facial aging. Rejuvenation of the aging face, therefore, requires a multimodal approach to attain an overall natural and uniform result that is long lasting. Fat grafting has become a very important method for restoring facial soft-tissue atrophy, while facelifting procedures address the ptosis and descent of facial and neck tissue. Read More

Authors:

As the popularity and acceptance of facial and cervical rejuvenation procedures grows, surgeons are increasingly encountering patients with less favorable anatomical characteristics for rhytidectomy. These patients will typically display an obtuse cervicomental angle, underprojected chin, excess cervical adiposity, and platysmal banding, in addition to ptotic submandibular glands, tenacious jowls, and prejowl volume deficits. Recognition of these problems and the correct application of available techniques to address the difficult neck in facelifting are critical in maximizing success. Read More

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